Defense Health Care: DOD Should Monitor Urgent Referrals to Civilian Behavioral Health Providers to Ensure Timely Care

What GAO Found

DOD's Defense Health Agency (DHA) oversees the TRICARE program, which offers behavioral health care to active-duty service members. DOD aims to provide this care at its military treatment facilities (MTF), but may also refer service members to civilian network providers. GAO's analysis of DHA data found that in fiscal year 2022, service members obtained routine and urgent specialty behavioral health care appointments (e.g., psychotherapy and substance use disorder treatments) at MTFs within required time frames (see figure). For referrals to civilian network providers, appointments after routine referrals fell just outside time frame requirements. Regarding appointments after urgent referrals, DHA has not established a specific time frame, but MTFs are instructed to use such referrals when expedited care is needed. GAO found average appointment wait times following these referrals ranged from over 2 weeks, to more than 3 weeks, depending on the region.

Average Days to Active-Duty Service Members' Initial Specialty Behavioral Health Care Appointments, Fiscal Year 2022

Note: MTF urgent behavioral health care appointments should generally occur within 24 hours. For all other initial specialty appointments, including with civilian providers, DHA applies a 28-day standard.

Provider vacancies were the main challenge to maintaining behavioral health care appointment availability for service members, according to officials at the six MTFs GAO selected for site visits. This is consistent with DHA-wide data, which showed vacancy rates for MTF civil service behavioral health care providers exceeded 40 percent, as of January 2023. To mitigate the effects of provider vacancies, officials from selected MTFs reported taking several steps, including increasing referrals to civilian network providers and prioritizing initial over follow-up appointments. DHA officials also reported taking mitigation steps, such as piloting a new triaging approach to better match patients' needs to level of care.

GAO found that DHA generally monitors the timeliness of behavioral health care provided to its service members under TRICARE. However, because there is not an established time frame for obtaining specialty appointments specific to urgent referrals to civilian network providers, DHA monitors urgent and routine network referrals in the aggregate rather than separately. As a result, DHA does not know the extent to which service members with urgent behavioral health concerns are experiencing delays obtaining the critical care they need following a referral outside an MTF. It also is not able to identify factors that may be contributing to delays and in turn, address any timeliness issues.

Why GAO Did This Study

Military service may carry a psychological cost for active-duty service members. Recent research has shown a fourfold increase in behavioral health conditions for this population. If left untreated, such conditions can affect deployment readiness, among other negative consequences.

A House report includes a provision for GAO to examine efforts to address mental health under the Department of Defense's (DOD) TRICARE program. This report (1) describes DHA data on average days to outpatient specialty behavioral health care appointments for active-duty service members in fiscal year 2022; (2) describes challenges to availability for these appointments at selected MTFs and steps taken to mitigate those challenges; and (3) examines relevant DHA oversight efforts.

GAO reviewed DHA documents and interviewed agency officials; analyzed DHA data on behavioral health care appointments in fiscal year 2022 (the most recent available) and staffing levels in fiscal year 2023; and conducted site visits at six MTFs, selected for variation in military service affiliation, installation size, and geographic location.